Medicare Part D and Payers Supplemental to Part D

Recommendations for Effective 4Rx Usage in Medicare Part D Processing

These documents were created by the industry to address a Centers for Medicare and Medicaid Services (CMS) directive entitled “Clarification of Unique BIN (or BIN/PCN) Requirements as of January 1, 2012 [§423.120(c)(4) as revised by CMS-4085-F]” which was released on November 12, 2010 that provided clarification of Unique BIN (or BIN/PCN) requirements. This directive covered the required assignment and exclusive use of unique routing and beneficiary identifiers for the Medicare Part D program. Implementing this directive consistently in the industry is the subject of the documents. The intent of these provisions is to ensure that:

  1. Pharmacies can routinely identify situations in which they are being reimbursed for a Medicare Part D claim.
  2. Payers supplemental to Medicare Part D can identify when a claim is being billed for a covered Medicare Part D beneficiary and drug so they can properly coordinate benefits.

These documents only address the matching and the consistent use of the 4Rx data to accept or reject transactions in processing. The intent of these documents is to provide:

  1. Clear guidance on how plans should submit 4Rx information on the MARx file to CMS when a plan or processor does not use PCN or group or only matches on a portion of those fields.
  2. A standard method for plans to communicate to pharmacies correct Part D 4Rx when a claim is submitted with incorrect 4Rx.
  3. Clarification on when to use the new benefit stage qualifiers to clearly indicate to the pharmacy and downstream payers when a claim submitted under a Part D BIN/PCN is processed under something other than Part D as allowed by CMS.

4Rx Reporting Spreadsheet to Pharmacies

The NCPDP Telecommunication (WG1) 4Rx Reporting Spreadsheet to Pharmacies Task Group developed a spreadsheet that can be used by the Part D industry to share 4Rx information that requires updates in pharmacy systems.

Prescriber Outreach Letter

Effective December 1, 2015 Medicare Part D prescription claims will only be covered if the Prescriber is enrolled in Medicare or has a valid opt-out affidavit on file with his/her Medicare Administrative Contractors (MAC). Based on CMS evaluation of Part D claim data, 30% of the prescribers are not currently enrolled. To mitigate point of service rejections and patient care delays as of December 1, 2015, prescriber outreach is necessary. The Definition of a Valid Prescriber Task Group has developed a prescriber outreach letter template to assist with this effort. This letter may be used by pharmacy providers, PBMs, plan sponsors, and other impacted entities. The Prescriber Outreach Letter can be dowloaded here.

Medicare Part D Frequently Asked Questions

This document provides a consolidated reference point for questions that have been posed and warrant consistent application across the industry of Medicare Part D policy where claims or other applicable transactions, Prescription Drug Events (PDE) are involved. Please continue to review this link as the document is updated as needed.

Financial Information Reporting (FIR) Editorial Document

This document provides a consolidated reference point for questions that have been posed based on the review and implementation of the NCPDP Financial Information Reporting Standard Implementation Guide Version 1.0 and above, the Data Dictionary, and the External Code List. This document also addresses editorial changes made to these documents. Updated August 2016.

Best Available Evidence (BAE) Form

The NCPDP Medicare Part D Best Available Evidence Form (BAE) for Low Income Cost Sharing (LICS) is made available to NCPDP members and non-members to provide a uniform method for pharmacies to communicate documentation of eligibility for LICS to Part D plans on behalf of Medicare beneficiaries.

Recommendations and Guidance Documents

    • Date Published
    • November 2016

    Recommendations for Use of the NCPDP Telecommunication Standard to Prevent Use of Copayment Coupons by Medicare Part D Beneficiaries and Applicability to other Federal Programs

    This paper provides recommendations for the best available long term solution to prevent the use of copayment coupons for drugs paid for by Medicare Part D.

    • Date Published
    • September 2015

    Medicare Part D Post Point-of-Sale Claim Adjustments

    This document provides guidance to the pharmacy industry by documenting a common list of
    post point-of-sale adjustment scenarios and associating them to categories and actions outlined in CMS Prescription Drug Event Guidance for Post Point-of-Sale Claim Adjustments.

    • Date Published
    • April 2015

    Post Automated TrOOP Balance Transfer (ATBT) Process

    CMS Medicare Part D requires Part D Plan Sponsors to coordinate benefits for up to 36 months. Automated TrOOP Balance Transfer (ATBT) Process covers 17 months of the 36 month requirement. This white paper addresses a process to transfer the balances for the remaining 19 months and is called the Post Automated TrOOP Balance Transfer process.

    • Date Published
    • September 2014

    Hospice Information for Medicare Part D

    Representatives from the prescription drug and hospice industries participating in NCPDP’s WG9 Hospice Task Group have collaborated on the development of a draft two-page form that may be used either by the hospice or prescriber to provide the information necessary to satisfy the beneficiary-level prior authorization edit, for the sponsor to make a coverage determination, or by the hospice to prospectively communicate information to the Part D sponsor. The first page of the form captures the information necessary for the prior authorization of drugs in the four categories; the second page captures information on drugs related to the terminal illness and/or related conditions and specifies whether each of these drugs is the responsibility of the hospice or beneficiary. Instructions for Use.

    • Date Published
    • February 2014

    Part D Plans Moving Processors V.4.0

    The NCPDP Medicare Part D Plans Moving Processors white paper has been updated to include information about CMS Guidance to Alternative Routing Scenarios. This white paper outlines the scenarios relevant to Medicare Part D Plans changing processors and the tasks to ensure that coordination of benefits occurs for the plan years originally contracted with the prior processor. The paper has been updated with clarifications based on use.

    • Date Published
    • November 2013

    Medicare Part D Non-Plan of Record

    This document provides guidance for Medicare Part D Plans on how to transfer TrOOP and Gross Drug Spend accumulators when claims have been paid by a non-plan of record.

    • Date Published
    • June 2013

    NCPDP Overview of the Medicare Part D Prescription Drug Coordination of Benefits (COB) Process

    NCPDP has created this overview for all parties involved in managing Part D benefits for Medicare beneficiaries. The white paper provides a consolidated overview of the transactions required to properly coordinate benefits and track True Out Of Pocket (TrOOP) dollars or other out of pocket expenditures when a supplemental payer contributes to the beneficiary’s portion of the cost sharing remaining on a Medicare Part D claim.

    • Date Published
    • May 2013

    NCPDP Recommendations for a Standardized Process to Share Medicare Part D Opioid Overutilization Data Between Sponsors

    This white paper offers a standardized process for sharing Medicare Part D beneficiary information related to point-of-sale edits and overutilization information from a previous plan of record to the new plan of record. CMS now requires sponsors to communicate and share this information to help protect beneficiaries and reduce fraud, waste and abuse.

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